Information Sheet for Pharmacy Connectivity Incentive _PCI_ program

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Information Sheet for Pharmacy Connectivity Incentive _PCI_ program Powered By Docstoc
					                                     Information Sheet for
                          Pharmacy Connectivity Incentive (PCI) program
What is the Pharmacy Connectivity                                   Lodgment
Incentive (PCI) program?                                            Send completed and signed form to:
The Fourth Community Pharmacy Agreement provides                    Fax 02 6103 9026 or
funding for professional pharmacy programs and services             Mail Pharmacy Connectivity Incentive
until 30 June 2010. The support of eHealth activities is one             GPO Box 9826
of these priorities.                                                     Hobart TAS 7001
The PCI program will provide financial incentives to
pharmacies to maintain business-grade broadband internet
connections from 1 January 2008 until 30 June 2010.                 About the Pharmacy Connectivity
The program aims to:                                                Incentive (PCI)
•	   increase the number of pharmacies using                        Organisations should note that incentives vary depending
     business-grade broadband                                       on geographical location of the pharmacy and what
                                                                    broadband services the pharmacy can access (terrestrial,
•	   promote continued use of business grade broadband              wireless or satellite services). Information about what
     connections                                                    incentives will be paid and under what circumstances is
•	   encourage connection and support pharmacies using              available on The Pharmacy Guild of Australia website at
     PBS online                                                     www.guild.org.au/pci

•	   increase awareness and understanding by community              To claim the Pharmacy Connectivity
     pharmacists of internet technologies and IT issues             Incentive (PCI) you must be:
     more generally.
                                                                    i. recognised under Section 90 of the
The program includes a Start-up Security Allowance                     National Health Act 1953
that will be made available to eligible pharmacies that
have not previously been paid a Security Awareness                  ii. transmitting claims via PBS online
and Conformance payment under Broadband for Health:                 iii. the holder of a current Unique Identification Number
Pharmacy Program, or a Start-up Security Allowance                       (UIN) issued by Medicare Australia
under the program.
                                                                    iv. on a 12 month Eligible Service Plan with an endorsed
Only those pharmacies defined as an eligible pharmacy                   provider or where re-contracting is not provided by
may apply for the payment. An eligible pharmacy must be                 your Internet Service Provider (ISP), you must have
signed up to an Eligible Service Plan through an endorsed               previously been on a 12 month Eligible Service Plan
provider and be transmitting via PBS claims online.                     under PCI, or a 12 month Qualified Service Plan
An eligible pharmacy applying for the Incentive should                  under Broadband for Health: Pharmacy Program, and
refer to the PCI Participation Guidelines, which can be                 continue to be connected to an Eligible Service Plan,
found at www.guild.org.au/pci                                       and you must not have received an incentive payment for a
                                                                    claim within the previous 12 months.
Who should complete this form?
A pharmacy owner should complete this form on behalf of             What documents do I need to provide to
the pharmacy.                                                       Medicare Australia to claim the Pharmacy
                                                                    Connectivity Incentive (PCI)?
How do I complete this form?
                                                                          You will need to submit this form and the Statutory
When completing this application, refer to the PCI
                                                                          Declaration attached.
Participation Guidelines. The Participation Guidelines can
be found at www.guild.org.au/pci                                          Organisations that are claiming a satellite level
                                                                          incentive will need to submit evidence to Medicare
Assistance                                                                Australia that they have been unable to have an
If you need assistance completing this form call                          ADSL broadband service supplied to their location.
Medicare Australia on 1800 818 111** or                                   Please refer to the Participation Guidelines
                                                                          for further information which can be found at
email pci@medicareaustralia.gov.au                                        www.guild.org.au/pci




                                                          Page 1 of 5                                               4208.26.03.08
What is a Unique Identification Number
(UIN)?
A UIN will be issued to each eligible pharmacy which will
then entitle that specific pharmacy location to access
the incentive. The UIN can only be used by the eligible
pharmacy to which it has been issued. The UIN remains
with the pharmacy location for the duration of the program
and is to be recorded on all documentation related to the
incentive payment and the Start-Up Security Allowance
(e.g. the Incentive Claim Form and correspondence).
An eligible pharmacy which has not been issued with a
UIN should complete an Application for UIN form. This
form is available from the Medicare Australia website
www.medicareaustralia.gov.au then go to For Health
Professionals then go to PBS then go to Fourth
Community Pharmacy Agreement. UIN questions should
be directed to Medicare Australia on 1800 818 111**.
Where an eligible pharmacy has been issued with a UIN
under the Broadband for Health: Pharmacy Program the
numerical part of this number will remain the same for the
Pharmacy Connectivity Incentive (PCI) program and the
prefix (BFP) will change to PCI.

** Call charges apply to mobile and pay phone only




                                                        Page 2 of 5   4208.26.03.08
                          Pharmacy Connectivity Incentive (PCI) claim form
Pharmacy details                                                         9   Is the service installed?
                                                                             No              You are not eligible to claim. Please re-submit
1   Unique Identification Number (UIN)
                                                                                             once the service is installed.
    P C I
                                                                             Yes             Date service was installed
2   Pharmacy trading name
                                                                                                 /    /
                                                                         10 Endorsed Service Provider name
3   Pharmacy approval number

                                                                         11 Eligible Service Plan
4   Pharmacy location address

                                                                         12 Date that you entered into a contract with the Endorsed
                                                                             Service Provider
                                        Postcode
                                                                                     /       /
    Pharmacy mailing address (if different from above)
                                                                         13 Date that the contract is due to expire
                                                                                     /       /
                                                                         14 Cost of endorsed service for 12 months (all amounts
                                        Postcode                             exclude GST) where known
5   Phone number                                                                 $
    (   )
                                                                         Declaration
    Fax number
    (    )                                                               I declare that:
                                                                         I have read and understood the Pharmacy Connectivity
    Email
                                                                         Incentive program Participation Guidelines.
                                                                         I understand that failure to respond to an Audit request
    @                                                                    may result in Medicare Australia seeking full repayment of
                                                                         any Pharmacy Connectivity Incentives paid.
6   Are you transmitting claims via PBS online?
                                                                         Name of approved Pharmacist
    No        If no, you are not eligible to claim. Resubmit
              once transmitting claims via PBS online.
    Yes                                                                  (print in BLOCK LETTERS)
                                                                         Signature
Claim details
7   Are you claiming:
                                                                             -
                                                                         Date
          Pharmacy Connectivity Incentive (PCI)
          Start up Security Allowance (SSA)                                      /       /

                                                                         Privacy note
Broadband service details
                                                                         The information provided on this form is collected by
8   What type of connection do you have?                                 Medicare Australia for the purpose of administering payments
          Terrestrial (ADSL/Cable)                                       for this program through arrangements with the Department
                                                                         of Health and Ageing and The Pharmacy Guild of Australia.
          Wireless                                                       The collection of this information is authorised under the
          Satellite (attach technical report)                            Medicare Australia Act 1973.
                                                                         This information may be used by Medicare Australia to
                                                                         assess your eligibility for an incentive payment under
                                                                         the program. This information may be provided to the
                                                                         Department of Health and Ageing and The Pharmacy
                                                                         Guild of Australia for administration, statistical and policy
                                                                         development issues.
                                                               Page 3 of 5                                                       4208.26.03.08
          Pharmacy Connectivity Incentive Program (PCI) Statutory Declaration
                           (Statutory Declaration Act 1959)
This Statutory Declaration must be completed and signed by the pharmacy owner. Where a pharmacy is owned by more
than one owner, the signature on this Statutory Declaration must be on behalf of all owners.
The pharmacy owner(s) must have an Eligible Service Plan in place with an Endorsed Service Provider for a period of not
less than 12 months, or have previously been on a 12 month Eligible Service Plan under PCI or a Qualified Service Plan
under Broadband For Health: Pharmacy Program, and have renewed your contract on an Eligible Service Plan with an
Endorsed Service Provider who does not provide renewed contracts of 12 months or more.

I
(print name)

of


                                                                                                         Postcode

         (       )                                                                     /       /
Phone                                                              Date of birth
make the following declaration under the Statutory Declarations Act 1959:
  1. I am authorised to make this declaration on behalf of all owners (where there are multiple owners)
        No
        Yes
     2. An Eligible Service Plan is in place with an Endorsed Service Provider for a period of not less than 12 months, or
        have previously been on a 12 month Eligible Service Plan under PCI or a Qualified Service Plan under Broadband
        For Health: Pharmacy Program, and have renewed my/our contract on an Eligible Service Plan with an Endorsed
        Service Provider who does not provide renewed contracts of 12 months or more.
        No
        Yes
     3. The Eligible Service Plan was connected on:
             /       /

I understand that a person who intentionally makes a false declaration in a Statutory Declaration is guilty of an offence
under section 11 of the Statutory Declaration Act 1959, and I believe that the statements in this declaration are true in every
particular.
Signature of person making the declaration                        Declared at (place)


-                                                                                  /       /
                                                                   on (date)
before me (print name)


Signature of person before whom the declaration is made            Qualification


-
Address of person before whom the declaration is made              Note 1: a person who intentionally makes a false
                                                                   statement in a Statutory Declaration is guilty of an
                                                                   offence, the punishment for which is imprisonment
                                                                   for a term of four years—see Section 11 of the
                                                                   Statutory Declaration Act 1959.
                                      Postcode
                                                                   Note 2: chapter 2 of the Criminal Code applies to all
                                                                   offences against the Statutory Declarations Act 1959—
                                                                   see Section 5A of the Statutory Declarations Act 1959.

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A statutory declaration under the                                          Member of Engineers Australia, other than at the
Statutory Declarations Act 1959 may be made before—                        grade of student
(1) a person who is currently licensed or registered under a               Member of the Association of Taxation and
    law to practise in one of the following occupations:                   Management Accountants
    Chiropractor                      Patent attorney                      Member of the Australasian Institute of Mining and
    Dentist                           Pharmacist                           Metallurgy
    Legal practitioner                Physiotherapist                      Member of the Australian Defence Force who is:
    Medical practitioner              Psychologist                            (a) an officer; or
    Nurse                             Trade marks attorney                    (b) a non-commissioned officer within the
    Optometrist                       Veterinary surgeon                          meaning of the Defence Force Discipline
(2) a person who is enrolled on the roll of the Supreme                           Act 1982 with 5 or more years of continuous
    Court of a State or Territory, or the High Court of                           service; or
    Australia, as a legal practitioner (however described); or                (c) a warrant officer within the meaning of that Act
(3) a person who is in the following list:                                 Member of the Institute of Chartered Accountants
      Agent of the Australian Postal Corporation who is in                 in Australia, the Australian Society of Certified
      charge of an office supplying postal services to the                 Practising Accountants or the National Institute of
      public                                                               Accountants

      Australian Consular Officer or Australian                            Member of:
      Diplomatic Officer (within the meaning of the                           (a) the Parliament of the Commonwealth; or
      Consular Fees Act 1955)                                                 (b) the Parliament of a State; or
      Bailiff                                                                 (c) a Territory legislature; or
      Bank officer with 5 or more continuous years of                         (d) a local government authority of a State or
      service                                                                     Territory
      Building society officer with 5 or more years of                     Minister of religion registered under Subdivision A of
      continuous service                                                   Division 1 of Part IV of the Marriage Act 1961
      Chief executive officer of a Commonwealth court                      Notary public
      Clerk of a court                                                     Permanent employee of the Australian Postal
      Commissioner for Affidavits                                          Corporation with 5 or more years of continuous
      Commissioner for Declarations                                        service who is employed in an office supplying
                                                                           postal services to the public
      Credit union officer with 5 or more years of
      continuous service                                                   Permanent employee of:

      Employee of the Australian Trade Commission who is:                     (a) the Commonwealth or a Commonwealth
                                                                                  authority; or
          (a) in a country or place outside Australia; and
                                                                              (b) a State or Territory or a State or Territory
          (b) authorised under paragraph 3 (d) of the                             authority; or
              Consular Fees Act 1955; and
                                                                              (c) a local government authority;
          (c) exercising his or her function in that place
                                                                           with 5 or more years of continuous service who is
      Employee of the Commonwealth who is:                                 not specified in another item in this list
          (a) in a country or place outside Australia; and                 Person before whom a statutory declaration may be
          (b) authorised under paragraph 3 (c) of the                      made under the law of the State or Territory in which
              Consular Fees Act 1955; and                                  the declaration is made
          (c) exercising his or her function in that place                 Police officer
      Fellow of the National Tax Accountants’ Association                  Registrar, or Deputy Registrar, of a court
      Finance company officer with 5 or more years of                      Senior Executive Service employee of:
      continuous service                                                      (a) the Commonwealth or a Commonwealth
      Holder of a statutory office not specified in another                       authority; or
      item in this list                                                       (b) a State or Territory or a State or Territory
      Judge of a court                                                            authority
      Justice of the Peace                                                 Sheriff
      Magistrate                                                           Sheriff’s officer
      Marriage celebrant registered under Subdivision C                    Teacher employed on a full-time basis at a school or
      of Division 1 of Part IV of the Marriage Act 1961                    tertiary education institution
      Master of a court
      Member of Chartered Secretaries Australia

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